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ACUTE CONFUSION IN THE ELDERLY. Dr. Barbara Power April, 2010. Major Objectives. Describe common causes of delirium Recognize risk factors, and means of prevention of delirium Work up and treatment of delirium when it does occur, and management of behavioral problems.

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Acute confusion in the elderly

ACUTE CONFUSION IN THE ELDERLY

Dr. Barbara Power

April, 2010


Major objectives
Major Objectives

  • Describe common causes of delirium

  • Recognize risk factors, and means of prevention of delirium

  • Work up and treatment of delirium when it does occur, and management of behavioral problems


Synonyms for delirium

Acute confusional state

Organic brain syndrome

Toxic/metabolic encephalopathy

Out of it

Uncooperative

Synonyms for Delirium


Epidemiology in elderly
Epidemiology in Elderly

Prevalence :

  • On Admission 10 - 30%

  • ER 10 -18%

    Incidence:

  • In Hospital 10 - 56%

  • Post-operatively 15 - 53%

  • Cardiac Surgery 17 - 73%

  • ICU 70 - 87%


So what why is delirium important
So What?Why is Delirium Important?

3 criteria:

Common, Morbidity & Costly!

  • Death ~20-35%

  • Cognitive drop in 40%

  • Premature institutionalization

  • on admit? 15-24%

  • in hospital?14-31%

  • Ortho? 25-65%

  • ICU: 70%!

  • LOS doubles

  • ++ hospital $

  • Caregiver burden


Recognition of delirium
Recognition of Delirium

  • Previous studies 32%-66% of cases unrecognized by MD’s

  • Yale- New Haven study

    • 65% unrecognized by Physicians

    • 43 % unrecognized by nurses


Case delirium
Case - Delirium

Mrs G. 79 year old lady

  • lives alone, manages own apartment

  • slightly forgetful (according to daughter)

  • PMed Hx: HTN; Insomnia

  • Meds:

    • Hydrochlorothiazide 25 mg OD

    • Amitriptyline 50 mg qhs

    • Oxazepam 15-30 mg qhs

    • Occasional alcohol use


Case delirium1
Case - Delirium

Admisssion to Hospital

  • Tripped on rug, sustained a hip fracture

  • Brought to hospital. Spends 12 hours in ER waiting for bed

  • What are the risk factors that make Mrs. F vulnerable to developing delirium?

  • Suggest actions that could be initiated to reduce her risk of developing delirium


Case delirium2
Case - Delirium

Admisssion to Hospital

  • ORIF the following day

  • 1st POD

    • climbing over bedrails

    • shouting all night

    • sleeping in day

    • pulling out her IV’s

  • What are the key features of delirium that the MD should elicit in Mrs. G?


The First Question –What is this?

Is this Delirium?

Dementia??

Or something else???


Delirium

All Confusion is

Not Dementia

Always Consider

Delirium


Delirium

  • Definition:

  • a disturbance of consciousness with inattention that develops over a short time & fluctuates


Delirium dsm iv
Delirium (DSM-IV)

A: Disturbance of consciousness(reduced clarity of

awareness of the environment) with reduced ability to focus,

sustain or shift attention

B: Change in cognition (eg. memory deficit, disorientation,

language disturbance) or development of a perceptual

disturbance not due to pre-existing, established or

developing dementia

C: The disturbance develops over a short period of time

(hours to days) and tends to fluctuate during the course of

the day.

D. Evidence of aetiology


Delirium versus dementia

DELIRIUM

Acute

Inattention

AbN LOC

Fluctuations/minutes

Reversible

Hallucinations common

DEMENTIA

Gradual

Memory disturbance

N LOC

None/days

Irreversible

Hallucinations common only in advanced disease

Delirium versus Dementia?

It is common for Delirium to be superimposed on Dementia!


Confusion Assessment Method (CAM)

  • 1. History of acute onset of change in patient’s normal mental status & fluctuating course?

  • AND

    • Lack of attention?

  • AND EITHER

    • 3. Disorganized thinking?

    • Altered Level of Consciousness?

  • Sensitivity: 94-100%

    Specificity: 90-95%

    Kappa: 0.81

    Inouye SK: Ann Intern Med 1990;113(12):941-8

    Arch Intern Med. 1995; 155:301


    Testing attention
    Testing Attention

    • Formal methods:

      • MMSE: Serial 7’s, WORLD backwards

      • Digit Span: 5 forwards, 4 backwards

      • Days of Week, Months of Year backwards

    • Affects all other areas of cognition


    Delirium cognitive evaluation
    Delirium: Cognitive Evaluation

    • MMSE:

      • inaccurate tool to diagnose delirium as the patient:

        • fluctuates

        • has poor attention/concentration

      • helpful tool to demonstrate improvement in cognitive status when following patient.


    Psychomotor variants of delirium
    Psychomotor Variants of Delirium :

    • Hyperactive("wild man!"); 25%

    • Hypoactive ("out of it!“, “pleasantly confused”); 50% - Individuals often not recognized as they may not cause a disturbance so they don’t get ATTENTION

    • Mixed delirium (features of both), with reversal of normal day-night cycle (“sundowning”)


    Case delirium cam
    Case – Delirium: CAM

    • Acute /Fluctuating Course

    • Altered level of Consciousness

    • Inattention

    • Disorganized Thinking

    9 am

    1 pm


    Top 4 independent risk factors for delirium
    Top 4 Independent Risk Factors for Delirium

    Vision impairment:

    RR=3.5 (1.2-10.7)

    Any severe illness:

    RR=3.5 (1.5-8.2)

    Cognitive impairment: RR=2.8 (1.2-6.7)

    High Urea/Creatinine:

    RR= 2.0 (0.9-4.6)

    Inouye S. Ann Intern Med 1993: 119-474


    What causes delirium inouye delirium model
    What causes delirium:Inouye Delirium Model

    Frail 89 y.o. with baseline dementia

    Fit 65 y.o. who plays senior’s hockey

    Minimal precipitant needed

    Strong or repeated precipitant needed


    Added Independent PrecipitatingFactors in Hospital For Delirium(i.e.. bad things WE do to elderly patients):

    • Restraints (RR 4.4)

    • NPO status (RR 4.0)

    • 3+ new med/24 hr (RR 2.9)

    • Foley catheter (RR 2.4)

    • Any iatrogenic event (RR 1.9)

    Inouye SK, Charpentier PA, Precipitating Factors for Delirium in Hospitalized Elderly Persons. JAMA. 1996;275:852-857


    Causes of delirium
    Causes of Delirium?

    • brain’s way of demonstrating “acute organ dysfunction”

    • Anything that hurts the brain or impairs its proper functioning can provoke a delirium!


    I watch death mnemonic

    IInfection:   Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur

    I WATCH DEATHMnemonic


    I watch death

    I  Infection 

    WWithdrawal:benzodiazapines, ETOH,

    I WATCH DEATH


    I watch death1

    I  Infection 

    W  Withdrawal

    AAcute metabolic: electrolytes, renal failure, acid-base disorders, abnormal glycemic control, Calcium

    I WATCH DEATH


    I watch death2

    I  Infection 

    W  Withdrawal

    A  Acute metabolic

    TTrauma: head injury (SDH, SAH), pain, vertebral or hip fracture, urinary retention, fecal impaction

    I WATCH DEATH


    I watch death3

    I  Infection 

    W  Withdrawal

    A  Acute metabolic

    T Trauma

    C  CNS pathology

    HHypoxia from COPD exacerbation, CHF

    I WATCH DEATH


    Medication review
    Medication review:

    • Look at all prescriptions

    • include PRNs, regular, ETOH and OTC meds

    • Ask if anything has been added, changed or stopped

    • Watch for sleeping meds ie Gravol; Nytol,


    Miscellaneous causes of delirium
    Miscellaneous Causes of Delirium

    • Pain

    • Fecal Impaction

    • Urinary Retention


    In other words anything that makes an older person very very sick
    In other words, anything that makes an older person veryvery sick…

    …can cause a delirium in a vulnerable older person!


    Delirium workup
    Delirium Workup

    • On History:

      • time course of mental status changes?

      • association with other events (i.e.. meds, illness)?

      • Pre-existing impairments of cognition or sensory modalities?



    Physical exam
    Physical Exam medical tools:

    • Vitals: normal range of BP, HR Spo2, Temp?

    • Good physical exam: particular emphasis on Cardiac, pulmonary and neurologic systems

    • Hydration status ? (dry axilla=dehyd!; + LR ~3)

    • Also rule out

      • fecal impaction (DRE)

      • urinary retention (bladder U/S, in-and-out catheter)

      • Infected decubatis ulcer


    Delirium workup lab testing
    Delirium workup: Lab testing medical tools:

    • Basic labs most helpful!

      • CBC, lytes, BUN/Cr, glucose

      • TSH, B-12, LFTs Calcium, & albumin

    • Infection workup (Urinalysis, CXR) +/- blood cultures

    • Other investigations based on Hx- EKG/CT Scan/Drug levels


    Case delirium3
    Case - Delirium medical tools:

    Admisssion to Hospital

    • ORIF the following day

    • 1st POD

      • climbing over bedrails

      • shouting all night

      • sleeping in day

      • pulling out her IV’s

    • What are the main immediate treatments you would initiate?


    Helping to improve delirium
    Helping to improve Delirium medical tools:

    Once it starts, needs to ride its course; but you can make a difference!


    Delirium reduction
    Delirium Reduction: medical tools:

    • You can get improvement of delirium with such simple measures as:

      • Glasses

      • Using hearing aids

      • Fluids/nutrition

      • reducing noise

      • Early mobility

      • Familiar faces

    S Inouye A multicomponent intervention to prevent delirium in hospitalized older patients.N Engl J Med. 1999 Mar 4;340(9):669-76.


    Can we prevent of delirium
    Can We Prevent of Delirium medical tools:

    • Multi component intervention strategy targeted to 6 delirium risk factors

      Ref: Inouye SK, NEJM. 1999;340:669-676


    Yale delirium prevention trial risk factors intervention
    Yale Delirium Prevention Trial medical tools:Risk Factors Intervention

    Cognitive Impairment Reality orientation / therapeutic activities program

    Vision/Hearing impairment Vision / hearing aids / adaptive equipment

    Immobilization Early mobilization / Reduce immobilizing equipment

    Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of sleeping medication

    Dehydration Early recognition / Volume expansion

    Sleep deprivation Noise reduction strategies/sleep enhancement program

    Ref: Inouye SK, NEJM. 1999;340:669-676


    Yale delirium prevention trial significance
    Yale Delirium Prevention Trial medical tools:Significance

    • Practical intervention towards evidence based risk factors

    • Significant reduction in risk of delirium

      ( 9.9% in intervention group vs 15% in usual care)

    • Significant reduction in total delirium days


    Pharmacological rx goals
    Pharmacological Rx: Goals medical tools:

    • Reverse psychotic signs and symptoms

    • stop dangerous or potentially dangerous behavior

    • To calm the patient sufficiently to conduct the necessary evaluation and treatment


    Drug treatment of agitation
    Drug Treatment of Agitation medical tools:

    • Only 4 RCTs (largest N=73):

      • Neuroleptics preferable to benzodiazepines in most cases (except: PD, DLBD, ETOH)

      • Low dose high potency neuroleptics (e.g., starting at haloperidol 0.25-1 mg)

      • Newer “atypical” agents: no better than haloperidol

    • Avoid Combination Drugs – SINGLE Drug is better

    Lacasse et. al., Ann Pharm, 2006


    If severe agitation consider rx w high potency antipsychotic
    IF SEVERE AGITATION consider Rx w/ high potency antipsychotic:

    • Haloperidol: po/IM/(IV short acting):

      • start with 0.5 - 1 mg initial dose

      • Repeat dose of 0.25-0.5 mg Q30 minutes if patient remains unmanageable without adverse events until sedation achieved and continue monitoring

      • repeat cycle until acceptable response or adverse events occur

      • max suggested Haldol dose in frail elderly 3-4mg/24 hr

    • Maintenance: 50% loading dose in divided doses over next 24 hrs

    • Taper the dose as soon as possible

    • Avoid in individuals with Parkinson’s Disease


    Benzodiazepines
    Benzodiazepines antipsychotic:

    1. Avoid use in combination with antipsychotics - SINGLE drug is better.

    2. May cause distribution/increased agitation.

    3. Best reserved for Delirium 2o to alcohol / Benzodiazepine withdrawal.

    4. Relatively contraindicated in Delirium from Hepatic Encephalopathy.


    Summary recognition of delirium
    Summary - Recognition of Delirium antipsychotic:

    • Delirium is Common

    • Yale- New Haven study

      • 65% of cases unrecognized by Physicians

    • Don’t be part of that group!



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